MRS. M.R., 70 years previous and feminine, DOB: eight/01/1952, offered to the clinic unaccompanied with signs of a painful knee. Osteoarthritis SOAP NOTE SUBJECTIVE DATA ID: Mrs. M.R, 70 years previous and feminine, DOB: eight/01/1952, offered to the clinic unaccompanied with complaints of a painful knee. He seems to be a good supply of historic info.
CC: “As a result of I have been having discomfort in my knee for greater than a month, I’ve come to see you. Initially, the discomfort was intermittent, however it has change into constant and excruciating since final week.”
Mrs. M.R., a 70-year-old feminine affected person, has been complaining of left knee joint ache and stiffness for a number of months when she involves the clinic for remedy. It was said that the ache had occurred periodically over the earlier two weeks, that it was uninteresting and achy, that it didn’t radiate, that it was related to swelling of the joints and stiffness, that it was exacerbated when chilly, that it was mildly relieved by Tylenol, and that it was exacerbated when strolling for an prolonged time frame or standing for an prolonged time frame. A 7 out of 10 severity score was given to the knee by the affected person, albeit it might periodically dip to a four out of 10. Based on her, the joint stiffness is extra noticeable within the early morning hours after she will get up or after she has rested, however it diminishes because the day passes. She categorically denied having ever suffered from joint harm or having any members of the family who had suffered from arthritis.
PMH
Methyldopa 250 mg PO each day, multivitamins one pill each day, and Tylenol 500 mg PO PRN are the drugs that I’m presently taking.
No recognized allergic reactions to drugs, meals, or the setting have been recognized in her case.
The affected person has a historical past of hypertension and is taking remedy, however she doesn’t have another power sicknesses or surgical histories.
Social historical past is the research of the previous.
She is a widowed mom of three kids who lives alone in a small home within the countryside. Studying books is considered one of her favourite pleasures. To the perfect of her skill, she denies ever smoking or consuming alcohol, or utilizing unlawful substances previously. It’s her declare that her kids are supportive of her, that she all the time wears a seat belt, and that she doesn’t textual content whereas driving.
Ancestors and forefathers
A diabetic and hypertensive, her older brother just lately handed away from a coronary heart assault, and her mother and father are each deceased, along with her mom having diabetes in addition to lung most cancers and her father affected by hypertension and kidney failure.
System Evaluation and Analysis
Normal: She isn’t experiencing any signs resembling fever, chills, lack of urge for food, weak spot, latest weight modifications, or sensitivity to chilly or warmth.
HEENT: Head: She asserts that she has not had dizziness, convulsions, complications, or head accidents on account of the incident. Eyes: Even though she claims to haven’t any eye discomfort, imaginative and prescient loss, yellow sclera, or blurred imaginative and prescient, she reads with glasses. Ears: She doesn’t complain of tinnitus, ear discomfort, ear discharge, or listening to impairments, and he or she doesn’t have any issues about her listening to. The nostril: She denies having sneezed, bleeding from the nostril, runny nostril, or nasal congestion. Throat: She claims she doesn’t have any discomfort swallowing, problem swallowing, or hoarseness in her voice.
Pores and skin: She asserts that she doesn’t have any rashes or itching on her pores and skin.
Her cardiovascular system is unaffected, she experiences, with no chest discomfort, no palpitations, no edema, no orthopnea, no shortness of breath, and no stress within the chest.
Respiratory: She asserts that she doesn’t have difficulties respiratory, coughing, shortness of breath, or sputum manufacturing.
Gastritis: She states she has not skilled any of the next signs: a lack of urge for food, anorexia, stomachaches, nausea, heartburn, vomiting, diarrhea, or constipation.
Hematuria, burning on urine, and vaginal discharge had been all denied by the affected person. Genito-urinary: She denied oliguria, incontinence, frequency, hematuria, burning on urine, and vaginal discharge. A postmenopausal girl, she has not had a month-to-month interval in a really very long time and is worried about her well being.
Neurological: She claims she isn’t experiencing any complications, dizziness, ataxia, paralysis, stability issues, numbness, or tingling sensations presently.
Musculoskeletal: She complains of stiffness and discomfort in her left knee joint, however she doesn’t have any again or muscular points in any respect.
When it comes to her hematologic well being, she claims she doesn’t have any points with bleeding, anemia, or bruising.
A splenectomy and enlarged lymph nodes will not be amongst her claims of getting lymphatic illness.
Her psychiatric historical past is evident: She denies having skilled any reminiscence loss, nervousness, or disappointment, or having had any hallucinations or had any ideas of violence or suicide.
The next endocrinologic circumstances are denied by her: extreme sweating, polydipsia, polyuria, and chilly or warmth sensitivity
Allergic reactions: She asserts that she doesn’t undergo from allergic reactions resembling rhinitis, eczema, bronchial asthma, or hives.
OBJECTIVE INFORMATION
Indicators of Life:
BP: 135/87 mmHg, PR: 89, RR: 16, temperature: 97.9 levels Celsius
On room air, SpO2 is 98 %, Wt is 153, and
Peak: 5’7″; BMI: 24.
Analyzing the physique:
Normal Observations: She is well-dressed and seems to be in good well being. She has the flexibility to collaborate with folks, talk successfully, and keep direct eye contact. She is awake and acutely aware of the passage of time, her environment, and the presence of others.
Upon examination, her head is normocephalic and has regular hair distribution. She doesn’t have any scars or seen lumps on her head. On palpation, there are not any painful or obstructive lumps.
Eyes- Each eyes have clear sclera and conjunctiva, common extraocular actions, and a standard visible area, in accordance with the PERRLA classification system.
On otoscopy examination, the pinna is in a standard form, and the exterior auditory canal and tympanic membranes are clear and with out bulging, indicating that the ear is wholesome. It’s ample to do a whisper take a look at.
Nostril- The nostril has a standard form, with patent nasal nares and the nasal septum within the midline, and the sinuses are palpable. Nostril- The nostril has a standard form, with patent nasal nares and the nasal septum within the midline, and the sinuses are palpable.
If you happen to palpate her tonsils, you’ll discover that they aren’t swollen. Her uvula is in the course of her throat, her mucous membranes are moist and pink, and her posterior pharynx and tonsils are freed from erythema or exudate.
It has no scars or swellings on the neck, and it has quantity of elasticity. When the trachea is palpated, it’s discovered to be within the midline, there is no such thing as a discomfort, and the cervical lymph nodes will not be detectable.
Musculoskeletal: The left knee joint is swollen and discolored, however there are not any different abnormalities discovered within the joint. It was found that the left knee joint was hotter than the correct knee joint on palpation and that the left knee joint was additionally painful. It was additionally found that the left knee joint’s vary of movement was restricted and that there was crepitation within the joint. No abnormalities, ache, or restricted ranges of movement are current in any of the opposite joints.
Whereas the chest is examined, there are not any scars, irregularities, or hyperpigmentation, and the motion of the chest is symmetrical when respiratory is completed. When the chest was palpated, there was symmetrical growth on either side, no discomfort, and equal tactile fremitus on both aspect. On auscultation, a standard breath sound could be heard.
Gastrointestinal: The stomach seems to be flat, strikes with respiratory, and is freed from hyperpigmentation or scarring, in accordance with the examination. When she is auscultated in all quadrants, she produces three common bowel sounds in a single minute. It was tympanic on percussion, with no shifting dullness, even if the spleen and liver had been each uninteresting. No discomfort or organomegaly could also be felt within the stomach, which is heat and clean to the contact.
Clinically, all of her cranial nerves seem like intact, and her muscle tone seems to be regular all through her physique, together with her extremities. Though she walks with an irregular and uncharacteristically regular gait, she continues to have intact needle prick sensations in each her higher and decrease extremities.
The cardiovascular system was discovered to be regular with no chest anomalies, jugular vein engorgement, or scars discovered through the take a look at. On auscultation, simply the S1 and S2 sounds had been heard, and there have been no different noises or murmurs. Along with being perceptible, the peripheral pulses are of a daily price and rhythm, and their quantity can be regular, as is the capillary refill time.
Dermatology and integumentary: Her pores and skin is ethnically appropriate and freed from rashes or imperfections. Palpation reveals that the pores and skin is heat and nicely perfused, and that the turgor is common.
Outcomes of diagnostic exams: The affected person’s ESR, full blood depend, rheumatoid issue, and x-ray are among the diagnostic exams that may be performed on him.
ASSESSMENT
Differential Prognosis (a)
Osteoarthritis (OA) is a kind of arthritis that impacts the joints (prognosis code ICD-10-CM M19.90)
Orthoarthritis, often known as degenerative joint illness, wear-and tear arthritis, or major osteoarthritis, is outlined as a degenerative dysfunction with inflammatory parts that’s attributable to a biochemical breakdown of articular cartilage in synovial joints, as outlined by the authors Vina & Kwoh (2009). (2018). Swelling, joint soreness, and joint stiffness are all indicators and signs of gouty arthritis. He had soreness, stiffness, and a restricted vary of movement in his left knee joint, which was the topic of the case investigation.
Rheumatoid arthritis is the second kind of arthritis (prognosis code ICD-10-CM M06.9)
Based on Conigliaro et al., rheumatoid arthritis is a power, systemic, and inflammatory dysfunction outlined by ache and protracted symmetric polyarthritis of all synovial joints, in addition to different signs (2019). The affected person complained of edema, ache, and stiffness in his left knee joint, which was investigated additional.
Patellofemoral Arthritis is the third kind of arthritis (prognosis code ICD-10-CM M22.2X1)
Patellofemoral arthritis is characterised by the degeneration of cartilage within the articular surfaces alongside the trochlear groove and the underside of the patella (Sanders et al., 2017). Ache, stiffness, and irritation within the knee joint are the principle signs of this situation. After waking up within the morning, the affected person complained of stiffness, soreness, and swelling in his left knee joint.
PLANNING
a. Diagnostics:
A take a look at for erythrocyte sedimentation price (ESR) is described by Hale and colleagues as follows: “The erythrocyte sedimentation price (ESR) is a take a look at that measures the speed at which erythrocytes settle to the underside of a take a look at tube” (2019). The ESR is elevated within the presence of any sickness that causes physique irritation, together with the widespread chilly.
With a purpose to detect whether or not or not an sickness is current within the physique, an entire blood depend (CBC) is carried out on the affected person’s blood cells (Nah et al., 2018). An infection or irritation could be indicated by a lot of white blood cells, nevertheless excessive ranges of white blood cells will also be indicative of malignancy, bone marrow sickness, or autoimmune illness.
As outlined by Martz et al. (2016a), an X-ray is a diagnostic imaging know-how that creates photos of physiological buildings or tissues. As a result of radiography is extensively accessible, inexpensive, and permits for simple serial comparability, it’s the diagnostic instrument of alternative within the prognosis of osteoarthritis of the knee.
b. Therapy Technique
Based on Abramoff and Caldera (2020), the aim of treating osteoarthritis is to alleviate ache whereas concurrently enhancing the affected person’s purposeful state. In terms of treating osteoarthritis, a mix of non-pharmacologic and pharmacologic remedies is used. A number of examples of nonpharmacologic interventions embrace bodily remedy, weight reduction, warmth or chilly compressions, train, and affected person schooling. In terms of pharmacological remedy of osteoarthritis, medicine resembling analgesics and antiinflammatory drugs, in addition to intra-articular injections or duloxetine, are employed. Glucosamine/chondroitin sulfate three tablets thrice per day and oral celecoxib 200 mg as soon as a day had been prescribed to assist alleviate the discomfort she was experiencing.
c. Schooling of the Affected person:
• She will probably be taught on the significance of exercising and reducing weight, in addition to the necessity of avoiding salty and cholesterol-rich meals, consuming vitamin-rich meals, and collaborating in low-impact exercises. •
As well as, she ought to be instructed of the variations between osteoarthritis and different shortly progressing arthritides, and he or she ought to be reminded that she might want to return to the clinic for an additional appointment.
• Present the affected person with info and encouragement about non-pharmacological remedy choices.
• Advise and urge the affected person to take his or her drugs as directed by the doctor.
• Inform the affected person on find out how to make the most of chilly/warmth packs to alleviate their discomfort.
d. Referrals
Referral to a neurologist if the issue doesn’t enhance inside an inexpensive timeframe
• Referral to a medical skilled if the affected person complains of morning stiffness.
e. Observe-up
• If the ache is extreme, you need to return to the hospital inside 24 hours of being discharged.
• If the ache is minor to reasonable, schedule a follow-up appointment after two weeks to reevaluate the situation.
• If the issue doesn’t enhance after one month or if it’s not responding to prescribed drugs, schedule one other appointment.
References
Abramoff, B., and Caldera, F. E. (in press) (2020). Prognosis and remedy choices for osteoarthritis are mentioned on this article. Medical Clinics, quantity 104, quantity 2, pages 293-311.
The authors, P. Conigliaro, P. Triggianese, E. De Martino and G. L. Fonti have revealed a paper through which they talk about their analysis. The authors additionally talk about their analysis through which they talk about their analysis through which they talk about their analysis (2019). The remedy of rheumatoid arthritis is fraught with difficulties. Autoimmunity Evaluations, vol. 18, no. 7, pp. 706-713.
A. J. Hale, D. N. Ricotta, and J. A. Freed have revealed a paper through which they argue that (2019). Acquiring an estimate of the erythrocyte sedimentation price. Journal of the American Medical Affiliation, 321(14), 1404-1405.
Martz, H. E., Logan, C. M., Schneberk, D. J., and Shull, P. J. (2001). Martz, H. E., Logan, C. M., Schneberk, D. J., and Shull, P. J. (2016). Fundamentals of X-ray imaging, in addition to industrial methods and purposes CRC Press is a publishing firm.
E. H. Nah, S. Kim, S. Cho, S. Cho, and H. I. Cho (2018). The reference intervals for full blood counts and patterns of modifications in full blood counts throughout the ages of pediatric, grownup, and geriatric sufferers in Korea. The Annals of Laboratory Drugs, quantity 38, quantity 6, pages 503-511.
The authors, T. L. Sanders, A. Pareek, N. R. Johnson III, M. J. Stuart III, D. L. Dahm and A. J. Krych, have revealed a paper through which they talk about their analysis findings (2017). Incidence of patellofemoral arthritis following lateral patellar dislocation in a matched population-based research. The American journal of sports activities medication revealed a paper on this subject in its 45th difficulty, which was 1012-1017.
Vina, E. R., and Kwoh, C. Okay. (in press) (2018). A evaluate of the literature on the epidemiology of osteoarthritis. Present opinion in rheumatology, quantity 30, quantity 2, web page 160.
